Covid-19: How the lessons of HIV can help end the pandemicBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n216 (Published 16 February 2021) Cite this as: BMJ 2021;372:n216
Until covid-19 hit, Eric Kutscher was used to seeing people sunbathing on his daily walk through New York’s Central Park to his job as an internal medicine resident at New York University’s Langone Medical Center. Early in the pandemic they stopped sunbathing, only to reappear, in masks, by late May. And that, to him, seemed like a realistic accommodation to the pandemic. “If we just say always stay home and never be around anyone even with a mask on—that’s an unrealistic expectation of people,” Kutscher says. “Once the cases started to come down, I think people began to try and figure out what their level of risk tolerance was.”
Kutscher studied the HIV epidemic and immediately saw the parallels between AIDS and covid-19. In both diseases, a lack of public health guidance from the highest levels of the government left the public to navigate life in a deadly pandemic showing no signs of stopping. What emerged was the concept of harm reduction—a set of evidence based strategies designed to lower the risk of behaviours when total abstinence isn’t likely. Although harm reduction is most strongly associated with drug addiction and the use of syringe exchanges (where injecting drug users can trade used needles for clean ones), public health experts have applied the concept with some success across a variety of fields including HIV and teen pregnancy.
Now, physicians and epidemiologists alike are calling for harm reduction strategies to fight covid-19.
How it worked with HIV
Richard Greene, Kutscher’s colleague and his coauthor on a June 2020 JAMA opinion piece about the benefits of harm reduction for the pandemic,1 says that a harm reduction approach means acknowledging that abstinence-only approaches to coronavirus, HIV, and drug prevention haven’t worked in the United States.
Although it is currently safer to stay at home and always maintain physical distancing, Kutscher, Greene, and others argue that it’s not always possible. Someone without paid sick leave can’t stay at home if they have a fever and cough. Nor is it healthy for someone to not have social contact for months on end. Instead, they say, physicians need to help their patients understand the risks of their behaviour, and encourage them to meet their financial, physical, and social needs in the safest way possible. “We can empower them with resources around how they can reduce risk in very practical ways,” says Julia Marcus, an infectious disease epidemiologist at Harvard Medical School.
Forty years ago, as the AIDS pandemic first swept through the LGBTQ community and injecting drug users, senior public health officials remained largely silent on how to prevent the virus from spreading. The advice they did give was largely moralistic and shaming: don’t have sex and don’t share needles. Nowhere, Kutscher says, did officials acknowledge that having sex was a normal human behaviour that no amount of shame and stigma was going to stop. Nor could injecting drug users just stop, even if they were aware of the potential disease threat—such is the nature of addiction.
As scientists learnt more about HIV and how it was transmitted, however, it became clear that injecting drugs and having sex existed on a spectrum of risk. What’s more, individuals could turn to specific behaviours to reduce their risk, such as wearing condoms and not sharing needles. Marginalised communities promoted these strategies to each other, without official input or approval. This approach enabled high risk populations to learn to live with risks that weren’t going away any time soon. By regularly getting tested and relying on other strategies like condoms and reducing viral load, people could still enjoy sexual relationships. “The LGBT community, particularly gay men, have grown up with this idea of navigating risk and negotiating risk based on best medical knowledge,” Kutscher says.
With covid-19, restrictions on activities, however well intentioned, began to chafe by early summer 2020, reflected in the crowds that packed bars and restaurants as states began to reopen. Like the gay men in the early 1980s, Marcus and other public health experts began asking themselves whether there was a better way to approach the pandemic. What emerged was an organic movement to promote harm reduction for the coronavirus.
Harm reduction of covid-19
Harm reduction focuses on encouraging people to make positive changes without blame, shame, or stigma for their current behaviours. Researchers must also understand enough about the risk of transmission to identify situations in which the virus is most likely to spread.
The arrival of covid-19 has fundamentally changed how people think about risks and socialising, says Leana Wen, an emergency physician and public health professor at George Washington University, who previously served as health commissioner for the city of Baltimore. Having dinner in a restaurant, for example, is no longer a carefree chance to catch up with friends and grab a meal.
In the covid-19 pandemic, harm reduction doesn’t just mean wearing a mask. During the first lockdown in the Netherlands in the spring, the government advised people to find a quarantine sex partner (seksbuddy in Dutch). Japan focused on avoiding the “three Cs”—closed spaces, crowded places, and close contact—to prevent disease clusters. In the US, however, public health messaging has generally focused on strict lockdown measures. With the help of epidemiologists on social media and in the news, some Americans began to create their own harm reduction strategies. Meeting outdoors, for example, helped at the time by the milder spring weather, and special store opening hours for high risk customers only.
Many of these measures, however, require no small amount of privilege. Many black and Latinx Americans have fewer green spaces in their neighbourhoods to use for gatherings. Others might have to work in crowded places like stores and have no choice but to work among people who refuse to wear masks. But harm reduction can still be useful for these people, says Kutscher. Rather than accepting that there’s nothing they can do, vulnerable and marginalised people can find the best way to stay safe. If people can’t gather outside, maybe they can open a window or turn on a fan to improve airflow, he says.
In the early days of lockdown, many communities had shuttered parks and playgrounds to stop disease transmission, a move that Wen and Marcus think was shortsighted. The irony, Wen points out, is that in these outdoor play areas it is much easier to follow physical distancing guidelines and risk of virus transmission is dramatically lower than indoors. “Staying outdoors is a really important harm reduction strategy,” she said. “People need to see each other.” Kids and adults need to play and socialise, and if they don’t have a safe place to do it, they will probably turn to riskier options to meet their needs.
A key pillar of harm reduction is not shaming people who continue to engage in risky behaviours that might put others at risk. That’s where things get sticky. “Your individual right to your own freedom stops at the point that you impose something on someone else that they did not choose,” Wen says, such as not opting to isolate after a potential exposure or choosing not to wear a mask because someone doesn’t think it matters.
Still, doctors shouldn’t berate or judge their patients for their choices, Greene says. Constantly scolding a patient about their cigarette smoking might cause them to lie about quitting. That robs a doctor of the opportunity to help them stop. Someone being shamed about their mask usage might tell friends they’ve been wearing one even if they haven’t, making it harder for others to gauge how safe they are.
Marcus emphasises that not shaming someone about mask usage doesn’t mean that we must let it pass without comment. “It’s more about thinking pragmatically about the most effective way to get this person to put on a mask. And the most effective way is generally not to yell at them that they’re selfish,” she says.
Remember, says Greene, the reason people break rules is because we have a human need for pleasurable, social activities. That’s been challenged in the pandemic. Understanding that can help more than shame.
Provenance and peer review: Commissioned; not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
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